Surgical Club of the South West

A case of gastro-duodenal Crohn's disease was preSented, in whom there was also intestinal and colonic lnvolvement. He subsequently underwent a partial gastrectomy with Roux-en-Y anastomosis, dissecting the lrst 18ins of jejunum, which was macroscopically involved with Crohn's disease and post-operatively fared very well. As this was an unusual case and gastrou?denal Crohn's disease is relatively rare, this lead me to review the literature of gastro-duodenal Crohn's disease.

haemodymanic consequences of a chronic obstruction, such as that resulting from a progressive colonic cancer are unknown. A model of chronic progressive large bowel obstruction was developed in the mini-pig. This mimics the mechanical component of carcinomatous large bowel obstruction. Blood flow before and after obstruction of the upper rectum was measured by two techniques; the local injection of Xenon133 radioisotope and the intracardiac injection of radiolabeled microspheres.
The blood flow of the left colon, proximal to the obstruction, showed a 5 fold increase and the ileal blood flow doubled. In contrast there was a 13% fall in the blood flow to the caecum. Differential studies of mucosal and muscle blood flows showed a shunting of blood from the mucosa to the muscle and this shunting was most marked in the caecum.
These results may explain why the caecum is the first site to become gangrenous or perforate even when the obstruction is in the upper rectum. The study provides no contraindication to the primary anastomosis of the obstructed left colon.

EXPERIENCE WITH THE POUCH W. H. F. Thomson Gloucester
Restorative proctocolectomy is in its infancy and different techniques are offered by experts both in the mode and amount of rectal resection, the type of pouch construction, and the method of its suture and endo-anal anastomosis.
I have used the W Pouch with a single layer extramucosal edge-to-edge apposition for optimal constructional capacity on a consecutive series of 15 patients in the last two years, 14 for ulcerative colitis and one for polyposis coli. Three await closure of the defunctioning ileostomy.
One patient suffered a pelvic haematoma which became infected after presumably incomplete evacuation and required re-drainage. There have been no other problems, and no failure of Pouch construction of anastomosis.
The functional result in 11 of the 12 completed cases is encouraging. Six have two to three bowel actions a day; the others between four and six. Only one, who already had post-vagotomy diarrhoea takes gut sedatives. None have urgency. Mucus seapage occurs in most (though not all) but is only very slight and mainly at night. All have returned to full normal activities.
Functional dissatisfaction afflicts one patient, the only polyposis sufferer in the group. Chronically depressed (on drugs) and of inadequate personality, she was, in retrospect, unsuited for the procedure. The rest are delighted with their result and one has become pregnant. Only time will establish the operation's durability, however. Caesium 137 sources to a dose of 1500 cGy at 10 mm off central axis as a 12cm line source over a period of 1.14 hours. In appropriate cases the entire oesophagus can be irradiated in two consecutive applications.
In our pilot study 72 patients deemed inoperable either due to unresectable disease or turned down for major surgery on fitness grounds, underwent brachytherapy. Sixty-nine tolerated the treatment of which 80% had useful improvement in swallowing. One patient with trachial involvement developed a fistula and would not now be so treated. One patient developed radiation stricture which responded to bougienage. Squamous cell carcinoma and adenocarcinoma responded equally favourably.
CARCINOMA OF THE OESOPHAGUS. IS RESECTION WORTHWHILE?
B. Pickering and J. Rahamin Derriford Hospital, Plymouth The treatment offered for oesophageal cancer should aim firstly to restore the ability to swallow and secondly?hopefully?to prolong the patient's survival.
Surgical resection is still currently the only treatment to offer these, but it must be associated with a low mortality rate if it is to remain the first choice in all cases.
From this relatively new Unit the first 100 resections for oesophageal cancer have been analysed. 58 were male, 42 female with an age range from thirty to eighty; 30 patients were over 70 years; 58% adenocarcinoma, 42% squamous and there was macroscopic coeliac gland involvement in 47% of cases. Duration o' symptoms varied widely from 2 weeks to 18 months-There were no deaths at operation. There were six hoS' pital deaths, 4 from cardiovascular accidents and 2 from leaks. 34 patients are alive and in their 2nd to 7th year after operation. The survival times of the remainder varied between 2 and 56 months, all eating and swalloW' ing normal food.
Even witha 6% hospital mortality we feel that resection wherever possible is worthwhile.
Cambridge ^ When a donor liver has been obtained 10 hours is the maximum delay before it can be successfully tranS' planted into a patient and helicopters and police motor cycle teams may be needed for its transport. No account of tissue typing is taken as this would further prolong the delay. The most difficult part of the operation is often the removal of the diseased liver, particularly if there ha5 been previous surgery. Sometimes it is advisable to assist the circulation with a bypass, taking blood from the IVC to the aorta without using heparin as this pro' duces severe bleeding problems. The advent of CycloS' porin A has greatly simplified the problems of immune suppression. The postoperative care is so incredibly complex that there has to be a 1 ;1 doctor/patient ratio in the ICU. Over 300 liver transplants have now been done with survival up to 7 7 years. One third of the grafts are done in children and there is a better than 90% graft survival, though some of them have needed a second transplant. Pancreas transplantation is best indicated when a diabetic patient with renal failure is in danger of loosing his sight from retinitis. The tail of the pancreas is transplanted and the duct brought into the stomach, the vascular connections are made with the splenic vessels with a self closing a-v shunt to assist patency. The results of treatment of upper urinary tract stones in the Plymouth Health District during the twelve months since the introduction of these techniques is presented-Thirty patients underwent thirty-one P.C.N, procedures. There were twenty-six successful stone removals-In eighteen this was performed as a one stage procedure-Four patients had a previous tract established for ernergency decompression of acute obstruction. Four-^en stones were removed intact, the remainder were d|sintegrated with E.H.L. or U.S.L. Over fifty per cent of the patients were discharged within seventy-two hours ?f the procedure.
Twenty-seven patients underwent twenty-nine Ureteroscopic stone removals. Successful stone visualisation and disruption was achieved in twentyhree. The success rate was higher for stones in the lower |hird of the ureter. Most patients were discharged within ourty-eight hours of the procedure. These techniques ave significantly altered the pattern of stone surgery in his district in that only a single open surgical exploration 0r stone was necessary in twelve months and a signi- Plymouth ~^he transurethral resection reaction is a symptom comple* resulting from the intraoperative absorption of irrigating fluid, and the ensuing dilutional hyponatremia, 0ccurring during transurethral prostatectomy. This ^rnptom complex is synonymous with that which 0ccurs in association with the syndrome of inappropriate ar|tidiuretic hormone secretion ie. water intoxication Sec?ndary to compulsive water drinking. It is apposite to compare these two syndrome as I hope to demonstrate at serum antidiuretic hormone levels are also impli-Cated in the transurethral resection reaction (TURR). ?Wever, the majority of patients undergoing transr?thral prostatectomy have demonstrable evidence of '^"'gant absorption yet less than 10% of patients suffer he TURR. Hypothetically, therefore, it appears possible at there is a further aetiological factor involved such at some patients are able to tolerate a fluid load whereas others are not. To validate this theory, intraoperative Ranges in serum sodium concentration were correlated 'th the preoperative urine osmolality (as an indicator o ?ntidiuretic hormone (ADH) status). Those  (1) Those relating to the induction and development of self-consciousness: critical attitudes of others, selfcomparison with others normal, mistaken identity; (2) Those relating to a defence mechanism which the subject develops both to hide the abnormality from the sight of others and to disguise self-consciousness of it: camouflage techniques, restricted life style, artificial behaviour: (3) Those relating to the experience of unavoidable distressing activities, e.g. hostile teasing at school; (4) Those relating to a downgrading of the subject's self-concept, inferiority, etc.; (5) Those relating to consequent difficulties with interpersonal relationships; (6) Those relating to unsuccessful attempts to rationalise. Each of these symptoms causes the patient psychological distress and disables him/her from enjoying a normal lifestyle. Their identification preoper-ative^ enables the surgeon to judge the potential psychotherapeutic benefits of operations designed to normalise appearance and the degree of their elimination post-operatively provides a measure of the success of such operations.

KELOIDS D. J. Hartley Plymouth
This word is widely misused to refer to any red, thickened, pruritic scar.
Scars becomes thickened in their early maturation due to an excess of collagen synthesis over collagen de-gradation, but over a period of months flatten and soften.
However, if healing of the initial wound is delayed, e.g. by infection, ischaemia or tension, an hypertrophic scar results, thicker than normal. This also settles to a normal scar but is usually more protracted.
The hypertrophic scar eventually matures and remains confined to the actual area of the wound, whereas the keloid persists and invades the adjacent dermis. It is uncommon. It is identical histologically with an hypertrophic scar and is usually diagnosed retrospectively.
Keloids have an undoubted constitutional basis being common in Negroes, females and the young.
Certain anatomical sites such as the deltoid and presternal region have a high susceptibility.
Treatment is disappointing and should be aimed at prevention, by proper surgical technique, correct orientation of scars, and the avoidance where possible, of keloid-prone sites. For this reason, BCG vaccination in the deltoid should be condemned. Pressure garments, intralesional triamcinolone and superficial radiotherapy are usually unhelpful in established keloids.
Excision alone results in recurrence and should always be combined with one of the above.

CULTURED SKIN IN THE MANAGEMENT OF AN EXTENSIVE BURN C. Chapman Plymouth
The mortality of adult patients with extensive burns (defined here as burns involving more than 70% of body surface area) remains high in the United Kingdom.
It is hoped that now cultured skin is avilable the mortality in these casualties will be reduced.
M.C. a male patient aged 42 was admitted to the Burns Unit Derriford Hospital Plymouth three hours after sustaining scalds from a burst steam pipe. The body surface area involved was calculated at 78%.
After resuscitation the patient was taken to the operating theatre where an area of unburned skin in his left deltoid area was cleaned with alcohol. Threesplit skin grafts each approx 4cmx3cm were taken, wrapped in saline?gauze and placed in a Universal container which in turn was packed with ice. (Alternatively a full thickness elipse of skin could have been taken from his axilla). The specimen was taken to the skin culture Laboratory Birmingham Accident Hospital arriving there as requested less than three hours after it had been harvested.
In the laboratory the skin grafts were washed in saline, chopped into very small pieces with iris scissors and then digested with trypsin in a conical flask in an incubator for approximately thirty minutes. This digestion process was repeated six times. A cell count of the suspension was made and approximately two million liberated epithelial cells transferred to each culture flask. After ten days sub cultures were carried out, skin eventually being produced in forty culture flasks. The cultured skin was ready to transfer to the patient approximately three weeks after harvesting the skin grafts from the patient.
A week prior to the cultured skin being ready for transfer to Derriford the patients burns were debrided in the Operating theatre so that a granulating base was ready for the cultured skin when it was transferred.
The forty flasks containing cultured skin were transferred from the Birmingham Laboratory to Deriford Hospital by police car and on arrival were placed in an incubator at 37?C and in an atmosphere of 8% carbon dioxide.
The roofs of the plastic culture flasks were removed using a hot soldering iron, the culture fluid removed from the flasks and the enzyme dispase added. The Dispase helped lift off' the sheets of thin cultured skin from the underlying base so that the skin in each flask could be stapled to a piece of closely woven petroleum gauze without difficulty, so facilitating its movement to a petri dish pending its transfer to the granulating area on the patient. A routine skin graft dressing was then applied.
Other granulating areas on the patient were covered with conventional skin grafts which had been meshed.
There was a good take of the cultured skin. After further skin grafting the patient was discharged from hospital five months after his admission.
The cost of producing cultured skin compares favorably to treating these patients with porcine skin.  (3), in-operability (6) and late diagnosis (5). All patients had limb threatening ischaemia, due to failed arterial reconstruction (6), Pr|' mary arterial thrombosis (4) or late arterial embolis (4' Hyperpyrexia occurred in two patients but did not pre' vent completion of treatment. Treatment was discon* tinued in one patient because of purpura. One 90 year old patient died 17 days after successful thrombolytic therapy from ruptured abdominal aortic aneurysm. Successful recanalisation was achieved in six patients (three failed reconstructions, two late emboli, and one primary thrombosis). Of the eight failures, three patients claimed subjective improvement and only two went on to major amputation. Thrombolytic therapy by intravenous infusion still has a place in the management of acute ischaemia for the unfit or in-operable patient. CAN  Epididymitis whilst usually resolving with appropriate antibiotic therapy may sometimes be complicated bV orchitis, intrascrotal abscess, testicular infarction and atrophy. These may result from testicular ischaemia caused by extrinsic compression of its blood supply bY constrictive funiculitis or by gross epididymal oedema-Under these circumstances prompt decompression by epididymotomy and lysis of the external spermatic fascia may prevent serious sequelae but selection for this procedure requires early identification of those testes at risk-We have attempted to do this by prospectively studying 31 men (age range 15-87 years) presenting to our Urology department with epididymitis. Besides various clinical parameters we also assessed the prognostic value of certain features on scrotal ultrasonography, in particular the epididymal and testicular size including the echo pattern of the latter and also the presence of a reactive hydrocele.
Testicular complications occurred in 14 men (45%)-Severe inflammation with involvement of the cord, the presence of a co-existent bacterial UTI and the finding during the acute episode of an enlarged testis displaying reduced echogenicity when compared to the contralateral side were findings that were significantly associated with an adverse outcome.
Epididymitis seen in hospital practice often involves the testis, sometimes with serious consequences. Scrotal ultrasonography is a potentially valuable adjunct in its management and warrants further study to determine its precise role.
*(Paper omitted from report of previous meeting in Bristol, Oct 1985 and awarded to S.W. Surgical Prize.)